Dear Colleagues

The theme of this issue of Heart & Science is Just Culture, a values-supported system of shared accountability adopted by BWH over a year ago.

In a Just Culture, “organizations are accountable for the systems they have designed and for responding to the behaviors of their employees in a fair and just manner. Employees are accountable for the quality of their choices, and for reporting their errors and system vulnerabilities.” (From The Just Culture Community)

I have heard some discussion about accountability and Just Culture that goes something like this: “How can we hold anyone accountable for the outcomes of their actions if we embrace a Just Culture?” I propose that embracing a Just Culture ensures that we do precisely that, in a principled manner.

We are fallible human beings first and professionals second. Because we are human, there can be no such thing as a zero error rate for a human task, though we can have zero tolerance for the reckless behavioral choices we make. If systems fail and human error prevails, in a Just Culture our role is to console those involved and take every opportunity to learn from the event, regardless of the outcome.

If an error occurs and we discover that it is not one individual but an entire group that has drifted to a workaround, straying from accepted standards, policies or procedures, then our role is to coach and remediate the behavior by naming it, educating and re-establishing expectations. If a behavior to which peers adhere and systems are in place to support, is not adhered to, but is not intentional, reckless or in a pattern, our role is to coach and counsel. On the other hand, if an error occurs and an individual who understands expectations willfully ignores standards, policies or procedures to which peers adhere, putting others at risk, regardless of outcome, our role is to discipline. Willful and reckless behavior are never justifiable, even if the error is a near miss and results in no harm.

The science of quality and safety has advanced significantly in my professional lifetime. As a novice nurse, I remember being disciplined with an intern for a medication error. The PDR, which we both checked, indicated an acceptable drug dose; a pharmacist approved the dose, but because there was no decision support to guide how the initial dose was to be given (i.e. tapered up gradually and modified based on the weight and age of the patient), the patient required narcan, to which he responded. The judgment that we had intentionally put a patient at risk weighed heavily on both of us, making us fierce advocates for more decision support and supervision.

Today, I am proud that I as a CNO and my colleague, now a cardiac surgeon, both have the opportunity to advance a Just Culture, engaging staff that come to work each day to work their hardest for patients in incredibly complex systems.